GW1-2021-06851_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For[nterngl Use ONLY: I
1.Well Contractor Information:
Mitchell Dean Cook la wamFxrtiTVlEs
FROM TO DFSCRD'770N
Well Contractor Name `9? ft ft, `
2043 A �� 1��1 ft. fl. j
NC Well Contractor Certification Number Sg\�n�� 1S t?UT•t+R rASIlVC4 for miilte ek ic(i?!'e t7f1+LI1F ,itC''}tea leT'
Y �NJ FROM TO DIAMETER CFIICF7VF.SS MATERIAL
Dennis Holland Well Drilling, Inc. pe��• :ft. ,ft. �„ ,o.
Company Name NF
FROM , TO I DIAMbTERharmal?clpidf-too
16 i1N ,R GASRyIy OR`TUBIiVCr a'a
TIIICKN SS I MATERIAL
2,Well Construction Permit#:�(7 s)-Q-i ./a R. ft. : in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): i7 S.(RFFN ,
Water Supply Well- FROM TO DIAMETER SLOT SI7,il E THICKNESS MATERIAL
❑A riculhual ft. to in.
g LIMullicipaVNblic
DGeothennal(Heating/Cooling Supply) OResidentW Water Supply(single) ft. fa in.
Cllndustrial/Commercial LM—sidential Water Supply(shared) ;Ig.GROU l ;; :• ,: _-.
FROM TO I MATE RIA14 I I EMPI ACFMFN'r MF.TIIOU&AMOUNT
Q 1171 atl0tl ft. i fr. q '
Non-Water Supply Well: �� %; -iz/>..,.
❑Monitoring GRecovery ft y fe
Injection Well: . ft. fr.
DAquifer Recharge LIGroundwater Remediation 19"UNt%GktnVEti FAGK'if a' Iici Ule
DAquifer Storage and Recovery USalinity Barrier FROKI TO nuTFRIAL I EMPLACF.MENFMETUOD s
ft. fr.
0Aquifer Test 08tormwater Drainage
ft. fL
LlExperimental Technology DSubsidence Control
>;`20.DR111 IN(v G0' ,attactf,edditrogat<ihectb!ifac'
DGeothermal(Closed Loop) LTrracer FROM TO D&SCREMON color,hudne soilfrock type,grain size etc.
DGeothermal Heatin Coolin Return ❑Other(explain under#21 Remarks) ft. ft./ ft. ft,
4.Date Well(s)Completed: -�2 Well ID# &,1 1. ft. fa
$a.Well Location: ` e, ft.
Facility/Owner Name Facility IDi!(ifapplicable) --1t. ff - --- — --•—
1-42l` �Lr%�u u'r w R1 �p � f._ c tF1 fC-r ft. ft.
Physical Address,City,and Zip=� T ';21:REIVIARI�1`
c 6.�
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N. 1 .
Signature ofCcrtified Well Contractor Date
6,Is(are)the well(s): IZ rmanent or OTemporary
By signing this jvrnt!hereby car!fy that Ihe well(,)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Stanrlarets and that a
7.Is this a repair to an existing well: !Yes or 9KI*o— copy q(this reccwd has:been provided ro the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under It21'remorkssection or on the back gjthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
H.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL,INSTUCI'IONS
9.Total well depth below land surface: C-3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdii ferent(example-S r)200'and 2@100') construction to file following:
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10.Static water level below top of casing: 1A (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
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11.Borehole diameter: 6" (in.) 24b. For lniecdion Well.I ONLY: In addition3o sending the fomt to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield rm . Airlift 24c.For Water Supply&Injection Wells: j
(g1 ) C7 Method of test: ._ r .
Also submit one copy of this form within 3d days of completion of
13b.Disinfection type: H & H Amount:.12 oz. _ well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Nahtral Resources-Division of Water Resoitrces Revised August 2013

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• -Q � applicant&
o��/ •m Macon County contact 3/1/21; NEW WELL CONSTRUCTION
,°� Public Health filed under CONSTRUCTION AUTHORIZATION
�d a� D (ECS) [ PRIVATE DRINKING WATER WELL
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Duran_Dodson and John Ellis • 620221 ip • 010813-s
Shared Well, Residential J ^_ ' 7t, MMW.91
• • Lot 6 Cullasaja Falls Estates
Highlands Rd to R on Emerald In to L on Beyond Oz Way to L on Hidden Village Trail to loft on R
Permit Conditions
Well shall be constructed in compliance with all NCAC 2C Rules.
Maintain minimum setbacks as applicable.
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Diagram (Not to Scale) �1
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Hidden Village Trail
Tran ormer
97'to top of cut bank
60
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E-29�
O ; s'
Large Pine 4--' Well Area
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Over 100
SP
P�
10
6 Over 1 oo'
�06d Ex. Drive
�a
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Ex.House
Septic systema
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This permit is valid for a Period of five Years except that it may be revoked at any time if it is determined that there has been a material change in any fact or
circumstance upon which the permit is issued. Well location, installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before it is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of;contamination. Flow volume(well yield)is N07
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS? [phone]
Issue Date: 2/26/2021 Justin Mintz, REHS 2177 r)% Authorized State Agent
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